对16只非鼻咽息肉性中耳炎猫的临床表现、诊断及治疗进行回顾性研 ...

王帆

Retrospective study of the presentation, diagnosis and management of 16 cats with otitis media not due to nasopharyngeal polyp

对16只非鼻咽息肉性中耳炎猫的临床表现、诊断及治疗进行回顾性研究

作者：Nicola Swales , Aiden Foster and Natalie Barnard

翻译：王帆

 

Abstract

Objectives The aim of this study was to analyse retrospectively cats diagnosed with otitis media (OM) not due to nasopharyngeal polyp, and to review the clinical outcome with surgical and medical management.

Methods Patient records were searched for cats diagnosed with OM. The diagnosis of OM was based on the presence of clinical signs, including neurological signs, respiratory signs and signs of otitis externa, and on the basis of evidence of thickened or irregular bullae walls, or the presence of fluid within the tympanic cavity; in those that had diagnostic imaging. In those that did not have imaging, the diagnosis was made on the basis of the presence of fluid in the bulla or organisms cultured using myringotomy. These records were analysed retrospectively.

Results Of 16 cats, one had a total ear canal ablation, five had ventral bulla osteotomy surgery and 11 were medically managed. Of the cats that were medically managed, using either topical products, systemic antimicrobials or a combination of both, eight had complete resolution of clinical signs.

Conclusions and relevance This small cohort shows that some cats with OM can be successfully managed medically. Surgery is invasive and may not necessarily be required if appropriate medical management is undertaken. This is the first study of OM treatment in cats and provides the basis for further studies, which should aim to establish specific infectious causes of OM and how they can potentially be managed with medical therapies.

摘要 

目的 回顾性分析非鼻咽息肉所致中耳炎猫的临床表现，并探讨其手术治疗和药物治疗的临床效果。

方法 查找诊断为OM的猫的病例资料。OM的诊断基于临床症状表现，包括神经症状、呼吸道症状和外耳炎的症状，并在那些有诊断影像病例上基于鼓泡壁增厚或不规则，或鼓腔内存在液体的证据。对于那些没有影像学检查的患猫，诊断依据是鼓泡内存在液体或鼓膜切开术细菌培养。对这些记录进行回顾性分析。

结果 16只猫，1只行全耳道消融术，5只行腹侧鼓泡截骨术，11只行药物治疗。在使用外用药、全身抗菌剂或两者结合使用的药物管理患猫中，有8只猫的临床症状完全消失。

结论和相关性 该小数据研究表明，一些患有OM的猫可以成功地进行药物治疗。手术是侵入性的，如果采取了适当的药物管理，可能不一定需要手术治疗。这是首次在猫上进行OM治疗的研究，为进一步的研究提供了基础，这些研究应该旨在确定OM的特定感染病因，以及如何用药物治疗来控制它们。

Introduction

介绍

Otitis media (OM) is defined as inflammation of the middle ear; the tympanic bulla (TB), up to and including the tympanic membrane (TM). It is less common than otitis externa (OE; inflammation of the external ear canal and pinna) and is less common in cats than in dogs. Owing to the inaccessibility of the middle ear, OM can be challenging to diagnose and treat.

中耳炎(OM)定义为中耳、鼓泡(TB)，包括鼓膜(TM)的炎症。它比外耳炎(OE;外耳道和耳廓发炎)，在猫上比在犬上更少见。由于中耳不通，OM的诊断和治疗具有挑战性。

 

The feline middle ear consists of the TB; the bony shell, the tympanic cavity (TC) within, and the TM, which separates the middle ear from the external ear. Unlike in dogs, the TC is divided by a septum of bone, creating two compartments. The septum runs from mid-rostral to mid-lateral and has a small gap dorsally, allowing communication between the two compartments. In one review of OM, both compartments were affected more commonly (94%) than either the ventromedial or dorsolateral compartments alone (6%). This structural difference to dogs may potentially make treatment more challenging in cats.

猫中耳由TB组成，外边为骨质，内部为鼓室腔(TC)，以及分隔中耳和外耳的TM。与犬不同的是，TC由鼓室中隔分隔，形成两个腔室。鼓室中隔从吻侧中部延伸到外侧中部，背侧有一个小孔，允许两个腔间的连通。在一篇关于OM的综述中，两个腔患病比例(94%)高于单独的腹内侧腔或背外侧腔(6%)。这种与犬的结构差异可能会使对猫的治疗更具挑战性。

 

A variety of clinical signs are associated with OM in cats. OE and signs of upper airway obstruction (inspiratory noise, nasal discharge and dyspnoea) are common, along with signs of vestibular disease, including head tilt, circling, nystagmus and ataxia. Cats presenting with ipsilateral Horner’s syndrome are common, owing to damage to the palpebral branch of the facial nerve. Non-neurological, non-specific clinical signs may include head shaking, pruritus, pain and altered ear carriage. Hearing deficits have also been reported in cats, owing to fluid in the TB or damage to the ossicles of the middle ear.

多种临床症状与猫的OM有关。常见OE和上呼吸道阻塞的症状(吸气噪音、鼻分泌物和呼吸困难)，同时伴有前庭疾病的症状，包括头倾斜、转圈、眼球震颤和共济失调。患猫常见同侧霍纳氏综合征，这是由于面神经的睑支受损。非神经系统、非特异性临床症状包括甩头、瘙痒、疼痛和耳姿势改变。听力受损在猫也有报告，由于TB内有液体或损害中耳听小骨。

 

There are several methods for diagnosing OM in cats. Because of their relatively short external ear canal, visualising the TM using otoscopy is relatively easy. Radiography, CT and MRI are commonly used, with CT and MRI being considered more sensitive. Myringotomy can also be useful to collect diagnostic samples from the TB. OM in cats most commonly presents as a result of a nasopharyngeal polyp (NPP) or pharyngeal or upper respiratory infection, which has extended up through the Eustachian tube. Less commonly, OM occurs as an extension of OE and it has also been suggested that a potential cause could be haematogenous spread.

诊断猫OM有几种方法。由于它们的外耳道相对较短，使用耳镜观察TM相对容易。常用x线检查、CT和MRI，CT和MRI被认为更敏感。鼓膜切开术也可用于从TB采集样本进行诊断。猫的OM最常见的表现是鼻咽息肉(NPP)或咽部或上呼吸道感染的结果，这些感染已通过咽鼓管向上延伸。不太常见的是，OM是OE向内的延伸，也有人提出，一个潜在的病因可能是血液播散。

 

OM can either be managed medically or surgically. In cats there is little, if any, information regarding medical management of OM not caused by an NPP. It has been suggested that there is an increased risk of ototoxicity in cats compared with dogs when using topical medications. The aim of this study was to analyse retrospectively cats diagnosed with OM not due to NPP, and look at the clinical outcome with surgical and medical management. The authors hoped to provide some recommendations for treating OM in cats not caused by an NPP.

OM可以通过药物或手术治疗。在猫中，几乎没有关于非NPP引起的OM的药物管理信息。有人认为，猫在使用外用药物时，耳毒性的风险比犬高。本研究的目的是回顾性分析非NPP所致OM的猫，并观察手术和药物管理的临床结果。作者希望为非NPP引起的猫OM的治疗提供一些建议。

 

Materials and methods

材料和方法

A search was performed in the practice management computer record system, using the keywords ‘CT bullae’ and ‘otitis media’, for cats. The results were then analysed to check that they fit the criteria; namely, cats of any age that had been referred with or diagnosed at the hospital with OM. Cats with only a presumed diagnosis were excluded, as were those that had CT scans of their bullae for reasons other than OM, such as traumatically avulsed ear canals. Any cat with mention of a middle ear polyp, NPP or ‘soft tissue-attenuating material’ in the bulla was also excluded.

在临床管理计算机记录系统中使用关键词“CT鼓泡”和“中耳炎”搜索猫。然后分析结果，以检查他们是否符合标准;也就是说，任何年龄的猫都被转诊或在医院诊断为OM。只有怀疑诊断的猫被排除在外，那些因OM以外的原因(如外伤性耳道撕脱)对鼓泡进行CT扫描的猫也被排除在外。任何提到中耳息肉、NPP或鼓泡中“软组织衰减物质”的猫也被排除在外。

 

The diagnosis of OM was based on the presence of clinical signs, including neurological signs, respiratory signs and signs of OE, and on the basis of evidence of thickened or irregular bullae walls, or the presence of fluid within the tympanic cavity, in those that had diagnostic imaging. In those that did not have imaging, the diagnosis was made on the basis of the presence of fluid in the bulla or organisms cultured using myringotomy.

OM的诊断是基于临床症状，包括神经症状、呼吸道症状和OE的症状，以及有影像学诊断的鼓泡壁增厚或不规则，或鼓室内存在液体的证据。对于那些没有影像学检查的患猫，诊断依据是鼓膜切开术后鼓泡内存在液体或微生物培养。

 

The case files were then analysed and data entered onto an Excel spread sheet. Clinical signs at first presentation were noted, diagnostic techniques employed at the referring practice and the referral hospital, and treatments prescribed. Descriptive statistics were derived from these data using simple percentages. The referring veterinary practice was contacted by telephone to request an up-to-date clinical history for each cat, since its referral.

然后分析案例文件，并将数据输入到Excel电子表格中。临床症状在第一次介绍注意，诊断技术在临床和转诊医院，和治疗处方。描述性统计是用简单的百分比从这些数据中得出的。我们通过电话联系转诊兽医，要求为每只猫提供转诊以来的最新临床病史。

 

Results

结果

Signalment

特征

A total of 16 cats were diagnosed with OM between 2011 and 2016, of which 50% were unilaterally affected and 50% had bilateral OM.

2011 - 2016年间共有16只猫被诊断为OM，其中50%为单侧患病，50%为双侧OM。

 

The majority were under 10 years of age (5/16 [31.3%] under 5 and 7/16 [43.8%] aged 6–10 years; 12/16 were less than 10 years old). An equal number were male and female, most of which were neutered. The most commonly seen breed was the domestic shorthair (11/16 [68.8%]). Other breeds seen were domestic longhair, Siamese, Maine Coon, British Shorthair and Burmese.

以10岁以下为主(5岁以下5/16[31.3%]，6-10岁7/16 [43.8%]);12/16小于10岁)。雄性和雌性的数量相等，大部分都被绝育了。最常见的品种是家养短毛猫(11/16[68.8%])。其他品种还有家养长毛猫、暹罗猫、缅因猫、英国短毛猫和缅甸猫。

 

Presentation

就诊记录

Half of the cats seen at the referral hospital had shown signs of OE either at the referring veterinary surgery or on presentation at the hospital, of which four had concurrent neurological signs. Figure 1 shows the clinical signs observed in the cats included in the study. A high proportion of cases (11/16 [68.8%]) presented with neurological signs, of which four had OE and neurological signs concurrently.

在转诊医院看到的猫中，有一半在转诊兽医外科或在医院就诊时表现出OE症状，其中4只同时出现神经系统症状。图1显示了在研究中观察到的猫的临床症状。神经症状占比较高(11/16[68.8%])，其中4例同时有OE和神经症状。

 

Diagnostic investigations/tests at the referral hospital

在转诊医院进行诊断调查/化验

Eleven of 16 cats (68.8%) had a CT scan of their bullae, all of which had evidence of fluid in the bullae and four had bulla wall thickening. Four had MRI scans rather than CT (18.8%), of which 100% showed enhancing material in the bullae (see Figure 2). Two cats had evidence of otitis interna (one showing enhancement of inner-ear structures on postcontrast images; one having a large and distorted inner ear and enhancement of the semi-circular canals) and one of the two had concurrent meningitis.

16只猫中的11只(68.8%)对它们的鼓泡进行了CT扫描，所有的鼓泡都有液体的症状，4只鼓泡壁增厚。4只猫进行了MRI扫描，而非CT扫描(18.8%)，其中100%的猫鼓泡显示增强物质(见图2)。两只猫有内耳炎的证据(一只猫在增强后图像显示内耳结构增强;其中一猫内耳大而变形，并有半规管增强)，另一猫同时患脑膜炎。

 

Of the four cats that showed evidence of bulla wall thickening, one was treated medically with systemic itraconazole and a topical preparation containing polymyxin B, prednisolone and miconazole (Surolan; Elanco), one underwent a ventral bulla osteotomy (VBO), one was recommended a VBO and one underwent total ear canal ablation (TECA). No recurrence was noted in the three cats that received treatment; no follow-up information was available for the cat that was recommended for VBO surgery.

在4只出现鼓泡壁增厚的猫中，1只接受全身伊曲康唑治疗，外用含有多粘菌素B、泼尼松龙和咪康唑的制剂，1例行腹侧鼓泡截骨术(VBO)， 1例建议进行VBO, 1例行全耳道消融(TECA)。3只接受治疗的猫没有复发;对于推荐做VBO手术的猫，没有后续信息。

 

Five cats had myringotomy procedures. Nine had cytology performed on the aural exudate (n = 4) or material obtained by myringotomy (n = 5). Samples from 9/16 cases (56.3%) were sent for culture and sensitivity testing; a variety of organisms were cultured, including Staphylococcus epidermidis and Staphylococcus aureus (with no significant antimicrobial resistance reported), Escherichia coli, anaerobes, Pasteurella multocida, Mycoplasma species and Pseudomonas aeruginosa (Table 1). The specific organism did not appear to influence the treatment modality or outcome.

五只猫接受了鼓膜切开术。9例对鼓膜渗出物(n = 4)或鼓膜切开术获得的样本(n = 5)进行细胞学检查。9/16例(56.3%)进行细菌培养和药敏试验;培养了多种微生物，包括表皮葡萄球菌和金黄色葡萄球菌(没有明显的耐药性报告)、大肠杆菌、厌氧菌、多杀巴氏杆菌、支原体和铜绿假单胞菌(表1)。特有微生物似乎不影响治疗方式或结果。

 

Treatment

治疗

Of the 16 cats with OM, six were treated surgically and 10 were managed solely medically. Seven of the cats managed medically were treated with systemic antibiotics (cefovecin [n = 1], marbofloxacin [n = 1], clavulanate-potentiated amoxicillin [n = 4, with one switched to clindamycin], pradofloxacin [n = 1] and cefalexin [n = 1]), based on the results of culture and sensitivity testing. Two were treated with systemic itraconazole and one also treated topically because Malassezia species were seen on aural exudate cytology. The duration of treatment ranged from 10 days to 8 weeks. See supplementary table for a summary of treatments received by each cat.

在16只患有OM的猫中，6只接受了手术治疗，10只只接受了药物治疗。根据细菌培养和药敏试验的结果，其中7只猫接受了全身抗生素治疗(头孢维星[n = 1]、马波沙星[n = 1]、阿莫西林克拉维酸[n = 4，其中1只改用克林霉素]、普多沙星[n = 1]和头孢氨苄[n = 1])。其中2例接受全身伊曲康唑治疗，1例接受外用治疗，因为在耳分泌物细胞学检查上发现马拉色菌。疗程从10天到8周不等。每只猫接受治疗的情况见补充表。

 

Outcomes

结果

One cat had a follow-up CT scan 5 weeks later and one had radiographs after 1 year; both these cats were successfully managed medically, with no signs of bulla effusion seen on the images, which had been present previously. Two cats had continual signs of OE after being medically managed but no signs of OM. Six cats have had no signs of ear disease, either OE or OM, as far as follow-up allows. Of the two cats with concurrent otitis interna, one had continued ataxia and both had head tilt, although these signs were less pronounced than on initial presentation. Follow-up available ranged from 3 months to 2 years. Four cats were euthanased, all for unrelated problems. For two cats, there was no available follow-up information (see Figure 3).

其中一只猫在5周后进行复诊CT扫描，另一只猫在1年后进行了x光片检查;这两只猫都药物治疗成功，没有在影响上看到以前鼓泡积液的症状。两只猫在接受药物治疗后出现持续的OE症状，但没有OM症状。6只猫每次复诊没有耳病的症状，无论是OE或OM。在同时患有内耳炎的两只猫中，一只持续共济失调，两只都有头倾斜，但这些症状不如最初表现明显。随访时间从3个月到2年不等。四只猫被安乐死，都是因为无关的问题。对于两只猫，没有可用的后续信息(见图3)。

 

Discussion

讨论

Managing OM in cats with surgical intervention has been well described;to the best of our knowledge there is very little information on medical management. This small, retrospective study shows some evidence that medical management with systemic antibiotics can be successful in treating cats with OM. The nine cats that were managed medically, for which follow-up was available, all appear to have been successfully treated. These results are potentially valuable for making clinical decisions when managing similar cases in future.

用外科手术治疗猫的OM已经有了很好的描述，但就我们所知，关于药物治疗的信息很少。这项小型的回顾性研究显示，一些证据表明，使用全身抗生素的药物管理可以成功治疗OM猫。这9只猫接受了药物治疗，并进行了后续随访，它们似乎都得到了成功的治疗。这些结果对于将来处理类似病例时做出临床决策具有潜在的价值。

 

Although there were no specific selection criteria in this study, it should be noted that diagnosis of OM in these cats was not solely based on imaging findings; the cats also had to have presented with compatible clinical signs. Previous studies have found that 34 cats out of a cohort of 100 had signs of OM on CT scans of the head yet presented with no signs consistent with ear disease.

虽然本研究没有具体的选择标准，但需要注意的是，这些猫OM的诊断并不仅仅基于影像学表现;这些猫还必须表现出兼容的临床症状。此前的研究发现，在100只猫中，有34只猫的头部CT扫描显示有OM的症状，但没有出现与耳病相一致的症状。

 

Studies show that CT and MRI are the most sensitive diagnostic imaging methods of diagnosing OM; it is not, however, known if they are the gold-standard method for monitoring for relapse. Resolution in these cases was based on resolution of clinical signs. Future prospective studies may wish to definitively measure resolution with a combination of advanced imaging techniques.

研究表明，CT和MRI是诊断OM最敏感的影像诊断方法;然而，尚不清楚它们是否是监测复发的金标准方法。这些病例的解决是基于临床症状的解决。未来的前瞻性研究可能希望结合先进的成像技术来最终测量分辨率。

 

There is a lack of evidence regarding the use of non-steroidal anti-inflammatory drugs (NSAIDs) in OM cases, whether for analgesia or to reduce inflammation. Although in these cases, it was used mainly for postoperative cases, there were some medically managed cats that also received NSAIDs. Each case was managed by clinicians from different specialities/disciplines so no standardised medical modality was used.

关于在OM病例中使用非甾体抗炎药(NSAIDs)的证据不足，无论是用于镇痛还是减少炎症。虽然在这些病例中，它主要用于术后病例，但也有一些接受药物治疗的猫也接受了非甾体抗炎药。每个病例由来自不同专业/学科的临床医生管理，因此没有使用标准化的药物管理模式。

 

It is stated in some review articles that antimicrobial medication is a valid treatment option in both dogs and cats, whereas others state that topical or systemic antimicrobials are far from ideal in the treatment of OM. These conflicting stances suggest that there is limited good-quality evidence on how to use systemic antimicrobials to treat OM and in which situations they are more likely to succeed, with particularly limited evidence for cats, especially as most of the available evidence is anecdotal or opinion-based, rather than being based on clinical trials. In this study, the duration of antimicrobial therapy did not correlate with outcome, although some cats had shorter durations of treatment than a proposed length of 4–6 weeks.

一些综述文章指出，抗微生物药物对猫和犬都是有效的治疗选择，而另一些文章则指出，外用或全身抗微生物药物对OM的治疗远非理想。这些相互矛盾的立场表明，关于如何使用全身抗菌素治疗OM以及在哪些情况下它们更有可能成功的高质量证据有限，尤其是针对猫的证据尤其有限，尤其是大多数现有证据都是轶事或意见，而不是基于临床试验。在这项研究中，抗微生物治疗的持续时间与结果无关，但一些猫的治疗时间比建议的4-6周短。

 

Some authors have stated that systemic antimicrobial therapies may not be able to reach a sufficient concentration in feline and canine bullae, even when given at the maximum oral dose.

一些作者指出，即使给予最大口服剂量，全身性抗菌疗法可能无法在猫和犬鼓泡中达到足够的浓度。

 

When planning to use systemic treatment in cats with OM, the results of bacterial culture are vital because this can influence which medication is prescribed. Topical treatment may be effective even if culture indicates a resistant organism, owing to the higher concentrations of drugs that can be applied topically to the ear, in comparison with systemic concentrations. In two cases described, infection with Mycoplasma species was reported. Mycoplasma species infection has also been reported as a cause for OM and Mycoplasma felis is an increasingly recognised cause of disease in cats.

当计划对患有OM的猫进行全身治疗时，细菌培养的结果是至关重要的，因为这可能会影响药物处方。即使细菌培养显示有耐药性，外用治疗也可能有效，这是因为与全身药物浓度相比，外用应用于耳部的药物浓度更高。报告2例支原体感染病例。支原体物种感染也被报道为OM的一个原因，猫科动物支原体是一个越来越被承认的猫的疾病原因。

 

This study is limited in that it was retrospective and not prospective; furthermore, the study population was very small. Even so, we hope that it will help to form the basis for further studies evaluating the success or otherwise of managing OM in cats with systemic antimicrobial treatment.

本研究的局限性在于它是回顾性的，而不是前瞻性的;此外，研究数量非常少。即便如此，我们希望这将有助于形成进一步研究的基础，以评估全身性抗菌治疗猫OM是否成功。

 

Conclusions

结论

This small cohort shows that some cats with OM can be successfully managed medically. VBO and TECA are invasive surgical procedures that may not necessarily be required in these cases if appropriate medical management is undertaken.

这一小数量研究表明，一些患有OM的猫可以通过药物治疗成功管理。VBO和TECA是侵入性外科手术，如果采取适当的药物管理，在这些病例中不一定需要手术治疗。

 

 

 

Figure 1 Summary of the clinical signs recorded for 16 cats with a diagnosis of otitis media. Resp = respiratory; TM = tympanic membrane

图1 16只确诊中耳炎患猫的临床症状总结。Resp =呼吸道;TM=鼓膜

 

 

Figure 2 Flow diagram for 16 cats diagnosed with otitis media (OM) with a summary of the diagnostic methods

图2 16只确诊为中耳炎(OM)的猫的流程图及诊断方法总结

 

 

Figure 3 Flow diagram summarising the treatment outcomes for 16 cats diagnosed with otitis media (OM). TECA = total ear canal ablation; VBO = ventral bulla osteotomy

图3 16只猫确诊中耳炎(OM)的治疗结果流程图。TECA=全耳道消融;VBO=腹侧鼓疱截骨术

 

 

Table 1 Bacterial culture and cytological findings

表1 细菌培养和细胞学检查结果

 

zhangenzyme

Ryohei

南海

杏子